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NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ


Root cause analysis is described as a range of possible approaches and tools obtained from the human factors and safety (Andersen and Fagerhaug, 2006). It provides the methods of identification of structured risks and their management in the aftermath of certain adverse events (Latino et al., 2019). This analysis is used to establish the ‘how’ and ‘why’ of the procedure and event with an attempt to identify the similar events. The application of root cause analysis is crucial in the health care system in improving the learning and incidence of mishandling (Peerally, et al., 2017). A root cause analysis of the medication administration errors in hospitalized patients was conducted. This paper describes the causes of the medication administration errors, regarding dose amount and negligence of changing notes, evidence-based solution strategy and planning to prevent such errors and ensure patient safety and quality of health in the organizational setting using the.

Scenario for identifying root cause analysis

  35 years old, Major, male, was admitted to the hospital in the general ward. He had a high BMI of 31.5, obese with complications of psychological eating disorder and stress. He had severe implications of diabetes and was prescribed with insulin doses two times a day before a meal, in the morning and at night, The nurse had to administer the dose of insulin intravenously after evaluating the glucose and keep a monitoring record on the retroactive chart. The night shift nurse measured the glucose to be normal, so she did not record it on the patient’s sheet. However, the nurse was required to report the readings to keep a record. The night shift nurse did not even verbally communicate with the morning shift nurse about the patient’s needs. Later the morning shift nurse couldn’t find the record of the previous administration of insulin, current glucose was 400 and she could find the clinical physician because of the busy floor. The strict timely administration policy of the medication took the nurse under pressure and she administered the two doses of insulin. Later the patient went to hypoglycemia with a feeling of dizziness and vomiting. The nurse felt guilty and was responsible for the error and the patient’s health. The medical error occurred due to multiple reasons, lack of communication, poor record-keeping and documentation on the retroactive sheet, increased workload pressure of work efficiency. The lack of communication and coordination of the nurses lead to suffering the patient from the previous condition of health degradation. 

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

Root cause analysis of the medication errors

The root cause of the medication error observed was multicentered related to the organizational, environmental and individual factors. The increased load of the work and busy floor reduces the quality of work, The lack of coordination of the nurses caused the patient to suffer. The nurse of the previous shift was supposed to administer the insulin and report it on the sheet, rather the nurse did not administer the insulin and did not even report it on the sheet which led to miscommunication of the documentation.  Medication administration is a key responsibility of the nurses; however, several nurses have reported certain environmental and individual factors (Friedman, et al., 2007) can interfere with the efficient medicine administration including, fatigue, workload, carelessness, negligence on nurses ends, poor coordination and communication between the nurses, inadequate balance of the staff and patient load, overcrowding of the hospitals and poor understanding of the procedure of administration (Shahrokhi, et al., 2013).

Considering the frequency of medication errors, poor coordination and documentation are the grassroots of multiple errors in health care. Efficient record-keeping of the medication, enough workforce and a positive working environment can influence the medication errors (Teixeira and Cassiani, 2014)

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

Evidence-based strategies

The safety of the patient is the core of health care provisions. Simulating a culture and organizational change of reporting the harms and preventing the adverse effect of the disease can enhance the efficiency of quality care to patients at hospitals (Abstoss et al., 2011). The job satisfaction of the nurses and reduction of nurse burnout along with flexible working time, the reduced workload can also improve the health care prevent the medication errors (Djulbegovic and Guyatt, 2017). For example, as in this case, the less crowding of the floor can lead to the easy availability of the physician and nurse can get guidance related to the dose administration the adverse drug effects and interactions can be prevented by computerized no intercepted record keeping, it can also reduce the cost of medication (Poon et al., 2010). In this case, the coordination of the nurses and enhanced communication measures along with sill building and decision-taking training (Pournamdar and Zare, 2016) can also provide better results as the nurses will be able to make decisions on an emergency basis and coordinate if necessary.

Improvement of plan with evidence-based practice

The issue faced in this paper regarding poor record-keeping can be amended by electronic record keeping which can be coordinated online with fellow nurses as well. Such a system would address the medication error and enhance safe efficient care practices (Bowman, 2013). Identification of patient safety foals and risk factors, enhancing coordination and communication strategies, skill-building of nurses and staff can prevent medication errors. The load of the work on the imbalance nurse-patient ratio requires recruitment of the appropriate staff (Cheragi, et al., 2013). The regular training and skill development of the nurses will enhance their knowledge and prevent the risk of medication errors. Patient awareness can also be beneficial in this regard. 

The goal of the health care provisions should be patient-centred safe health care provisions. The environmental and individual factors should be addressed to prevent the loss of medication and economic resources and prevent the long hospital stays of patients. 

Resources for implementation 

Medication error prevention measures require implementation and evaluation programs for policy measures. It will require personal resources at the end of nurses and hospital organizational resources to overcome the frequent medication issues. The drug interaction, overdosing, wrong administration and poor comprehension and negligence of the medication procedures will use most of the individual efforts. Nurses should be made more aware of the situation of the health care system while administering the medication. There should be no interruption, verbal, nonverbal. The nurse should check the previous history identify the patient to go forward with the administration process. After confirmation of the identity of the patient and his history the notes should be analyzed for the mediation requirements, any ambiguity should be addressed immediately to avoid any drug abuse and adverse effects. While administering the medicine any engagement of the mental and physical condition should be avoided. The nurse should use safe, hygienic and efficient protocols while administering the medicine intravenously to ensure the prevention of infection spread and mishandling of the syringe. The oral medication requires a reassessment of the correct dose and type to avoid overdosing. 

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

Organization management should be aware of the recruitment of the nurses according to the resources of the hospital. The number of requirements and patient load should be managed to avoid overcrowding. The hiring should be conducted on the basis of skill and knowledge to ensure the patient safety. It will require face to face interviews and practical questions while interviewing them. The working nurses should be polished for their skills by regular training sessions leading to personal preference, motivation, and encouragement for avoiding errors, reducing costs of the health care system and providing right and efficient care. 


Medication administration errors are common in hospital settings regarding record keeping, intravenous or oral dose, the quantity of dose and mishandling of administration procedure. The frequency of medication errors requires rigorous multisectoral planning and implementation structure, environmental, individual and organizational. The root cause analysis of the medication errors in the health care units described the lack of coordination, poor record-keeping, lack of decision making, overcrowding of the hospitals, imbalance of the patient and nurse ratio leads to workload and negative environment building. Implementation of the electronic record-keeping and in the evaluation of the prescriptions can avoid medication administration errors regarding overdosing and underdosing. The electronic system can save human fatigue and efficiently analyse the patient’s record. The online portal communication can prevent the misinformation of the dose and enhance communication and coordination errors.

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ


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Peerally, M.F., Carr, S., Waring, J. & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ quality & safety26(5), pp.417-422.

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Shahrokhi, A., Ebrahimpour, F. & Ghodousi, A. (2013). Factors effective on medication errors: A nursing view. Journal of research in pharmacy practice2(1), p.18.

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NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

Teixeira, T.C.A. & Cassiani, S.H.D.B. (2014). Root cause analysis of falling accidents and medication errors in hospital. Acta Paulista de Enfermagem27, pp.100-107.

Abstoss, K.M., Shaw, B.E., Owens, T.A., Juno, J.L., Commiskey, E.L. & Niedner, M.F. (2011). Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit. BMJ Quality & Safety20(11), pp.914-922.

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Pournamdar, Z. & Zare, S. (2016). Survey of medication error factors from nurses’ perspective. Biology and Medicine8(5), p.1.

Bowman, S. (2013). Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in health information management10(Fall).

Cheragi, M.A., Manoocheri, H., Mohammadnejad, E. and Ehsani, S.R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research18(3), p.228.NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ

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